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The Genitourinary System

Last updated 31 May 2026 Β· Nephrology / Urology

πŸ“‹ Key Information Summary

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  • Systematic renal history should cover dysuria, haematuria, frequency, nocturia, incontinence, erectile dysfunction, and constitutional symptoms of uraemia (nausea, pruritus, fatigue, peripheral oedema).
  • Nocturia β‰₯ 2 episodes/night in a middle-aged or older adult warrants investigation for CKD, benign prostatic hyperplasia (BPH), diabetes mellitus, or cardiac failure.
  • Visible haematuria is urological malignancy until proven otherwise β€” refer urgently for cystoscopy in patients β‰₯ 40 years.
  • CKD staging follows KDIGO 2012: G1 (eGFR β‰₯ 90) through G5 (eGFR < 15), combined with albuminuria categories A1–A3 to stratify risk.
  • eGFR is calculated using CKD-EPI 2021 (race-free) equation in Australia; always interpret in clinical context β€” a single low eGFR does not confirm CKD without repeat testing β‰₯ 3 months apart.
  • Dialysis patients require systematic assessment of vascular access (AV fistula thrill/bruit), fluid status, adequacy markers (Kt/V), and complications (anaemia, bone disease, cardiovascular risk).
  • Renal palpation: ballottement technique identifies a palpable kidney; a unilateral, non-tender, ballotable mass may indicate hydronephrosis or polycystic kidney disease.
  • Blood pressure measurement is fundamental β€” hypertension is both a cause and consequence of CKD; target < 130/80 mmHg in most CKD patients with albuminuria.
  • Urinalysis dipstick tests for protein, blood, glucose, ketones, nitrites, and leucocytes; positive nitrites + leucocytes strongly suggest urinary tract infection (UTI).
  • Male genitalia examination includes inspection of the penis (meatal position, discharge, lesions), palpation of the testes (masses, tenderness), and assessment of the scrotal contents (hernia, varicocele, hydrocele).
  • Aboriginal and Torres Strait Islander Australians have a 3.8-fold higher rate of CKD and disproportionately higher rates of kidney failure requiring renal replacement therapy β€” early screening and culturally safe assessment are essential.
  • Always consider referral to nephrology when eGFR declines by > 5 mL/min/1.73 mΒ² per year, ACR β‰₯ 30 mg/mmol, or when CKD aetiology is uncertain.

Introduction & Australian Epidemiology

The genitourinary (GU) system encompasses the kidneys, ureters, bladder, urethra, and male reproductive organs. A structured history and examination of the GU tract is essential in primary care, emergency medicine, and hospital settings to detect chronic kidney disease (CKD), acute kidney injury (AKI), urinary tract infections, malignancy, and reproductive disorders. In Australia, kidney disease is a major public health burden, affecting approximately 1.7 million adults and accounting for a significant proportion of hospital admissions, cardiovascular morbidity, and premature mortality.

Chronic kidney disease affects an estimated 11% of the Australian adult population, with prevalence rising sharply after age 60. Indigenous Australians experience CKD at rates 3.8 times higher than non-Indigenous Australians, with earlier onset and faster progression to kidney failure. Diabetes mellitus (particularly type 2) and hypertension remain the two leading causes of CKD nationally. The Australian Institute of Health and Welfare (AIHW) reports that over 14,000 Australians received kidney replacement therapy (dialysis or transplant) in 2022, with haemodialysis constituting the majority of treatments.

This article provides a systematic approach to genitourinary history-taking, clinical examination including CKD staging, dialysis patient assessment, urinalysis interpretation, and male genitalia examination. It integrates Australian clinical practice standards, KDIGO guidelines, and considerations relevant to the Australian healthcare context.

Epidemiological Measure Value (Australia) Source
Adults with CKD (stages 1–5) ~1.7 million (β‰ˆ11%) AIHW 2023
Patients on kidney replacement therapy > 14,000 (2022) ANZDATA 2023
Indigenous vs non-Indigenous CKD rate ratio 3.8Γ— AIHW CKD in Aboriginal and TSI peoples
Leading cause of CKD Diabetes mellitus (β‰ˆ 38%) ANZDATA 2023
Second leading cause of CKD Hypertension / vascular disease (β‰ˆ 22%) ANZDATA 2023
Prostate cancer incidence (new cases/year) ~24,000 AIHW Cancer Data 2023

Genitourinary History

A focused genitourinary history should be taken systematically, covering urinary symptoms (the "LUTS" spectrum), pain patterns, constitutional symptoms suggestive of renal failure, sexual and reproductive history, and relevant past medical and drug history. Use open-ended questions before narrowing with specific probes.

Urinary Symptoms

Urinary symptoms are broadly divided into storage symptoms (frequency, urgency, nocturia, incontinence) and voiding symptoms (hesitancy, weak stream, straining, terminal dribbling, incomplete emptying). The distinction guides differential diagnosis.

Symptom Definition / Key Questions Common Causes
Dysuria Burning or stinging pain during micturition; ask about suprapubic pain, urethral discharge, fever UTI (cystitis, urethritis), STIs (chlamydia, gonorrhoea), bladder stones, interstitial cystitis
Haematuria Visible (macroscopic) vs non-visible (microscopic); timing in stream (initial, terminal, total); associated clots, pain UTI, urolithiasis, malignancy (bladder, renal, prostate), glomerulonephritis, BPH, trauma, exercise-induced
Frequency Passing urine more often than usual; document number of times per day and volume pattern UTI, overactive bladder (OAB), diabetes mellitus, diabetes insipidus, diuretics, anxiety, CKD (impaired concentrating)
Nocturia Waking β‰₯ 1 time per night to void; β‰₯ 2 episodes is clinically significant in middle-aged adults CKD (impaired concentrating capacity), BPH, heart failure, obstructive sleep apnoea, diabetes mellitus, excessive fluid intake, medications
Incontinence Type: stress (cough/sneeze), urge (preceded by urgency), overflow (dribbling), functional (mobility/cognitive) Stress: pelvic floor weakness. Urge: OAB, UTI, neurological. Overflow: BPH, neurogenic bladder. Functional: dementia, immobility
Impotence / Erectile dysfunction (ED) Difficulty achieving or maintaining erection; ask about libido, morning erections, psychosocial factors, medication history Vascular disease, diabetes, CKD/uraemia, medications (Ξ²-blockers, SSRIs, thiazides), depression, post-prostatectomy, low testosterone
Renal failure symptoms Nausea, vomiting, anorexia, pruritus, fatigue, muscle cramps, peripheral oedema, dyspnoea, altered cognition, foetor uraemicus Progressive CKD (uraemia), AKI (pre-renal, intrinsic, post-renal obstruction)

Pain Assessment in Renal / Urological Disease

Pain character and radiation are important differentiators:

  • Renal colic: severe, intermittent (colicky) loin-to-groin pain; patient is restless and unable to find a comfortable position; associated with nausea, vomiting, and microscopic haematuria. Classic radiation: flank β†’ loin β†’ groin β†’ inner thigh (testis or labia).
  • Renal angle tenderness: percussion pain in the costovertebral angle (CVA) β€” suggests pyelonephritis, renal capsule distension (hydronephrosis, tumour).
  • Suprapubic pain: suggests bladder pathology (cystitis, urinary retention, bladder distension).
  • Testicular / scrotal pain: acute onset is testicular torsion until proven otherwise (surgical emergency). Dull ache is more consistent with epididymitis, varicocele, or tumour.
  • Flank pain: renal origin (pyelonephritis, renal cell carcinoma, polycystic kidney disease with capsular distension) β€” typically constant and dull.

Additional History Components

  • Fluid balance: fluid intake (type and volume), fluid output (urine volume estimate, oliguria < 400 mL/24 h, anuria < 100 mL/24 h), fluid balance chart if inpatient.
  • Past urological history: previous UTIs, renal calculi (stone type if known), urological surgery, prostate disease, catheterisation history.
  • Medications: nephrotoxic agents (NSAIDs, aminoglycosides, lithium, calcineurin inhibitors, ACE inhibitors / ARBs, contrast agents), diuretics, anticholinergics, Ξ±-blockers.
  • Family history: polycystic kidney disease (ADPKD), Alport syndrome, vesicoureteric reflux, medullary sponge kidney, renal cell carcinoma.
  • Social and occupational history: smoking (bladder cancer risk), occupational chemical exposures (aromatic amines, bladder cancer), alcohol, sexual history (STIs).
  • Systems review: weight loss (malignancy), joint pain (lupus nephritis, vasculitis), rashes (vasculitis, SLE), hearing loss (Alport syndrome), recurrent oral ulcers (BehΓ§et's, IgA vasculitis).
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Red flags in genitourinary history requiring urgent investigation: visible haematuria in patients β‰₯ 40 years (suspect malignancy β€” refer for cystoscopy within 2 weeks), acute testicular pain (suspect torsion β€” surgical emergency within 6 hours), anuria with hyperkalaemia (emergency urological/nephrological assessment), and loin pain with fever (suspect pyonephrosis or renal abscess).

CKD Staging (KDIGO) & Dialysis Patient Assessment

Chronic kidney disease is defined by KDIGO 2012 as abnormalities of kidney structure or function present for β‰₯ 3 months, with implications for health. Staging combines the glomerular filtration rate (G) category with the albuminuria (A) category to produce a comprehensive risk stratification.

eGFR Calculation in Australia

Australian laboratories use the CKD-EPI 2021 creatinine equation (race-free) to report eGFR. This replaced the MDRD equation and the older CKD-EPI 2009 equation. Key caveats:

  • eGFR is an estimate β€” it has limitations in extremes of body composition (very muscular, amputees, malnourished), pregnancy, acute kidney injury, and in patients with rapidly changing creatinine.
  • A single low eGFR does not confirm CKD β€” requires repeat measurement β‰₯ 3 months apart.
  • eGFR is unreliable below 15 mL/min/1.73 mΒ²; measured GFR (iohexol or iothalamate clearance) may be needed.
  • Cystatin C-based eGFR can be used as a confirmatory test when creatinine-based eGFR is unreliable.

KDIGO GFR Categories (G1–G5)

G Category eGFR (mL/min/1.73 mΒ²) Description Clinical Action
G1 β‰₯ 90 Normal or high Diagnose CKD only if other markers of kidney damage present (albuminuria, haematuria, structural abnormality, biopsy proven)
G2 60–89 Mildly decreased As for G1; address cardiovascular risk factors; annual monitoring
G3a 45–59 Mildly to moderately decreased Confirm chronicity; investigate cause; manage complications; consider nephrology referral
G3b 30–44 Moderately to severely decreased Nephrology referral recommended; active management of CKD complications (anaemia, bone disease, acidosis, hyperkalaemia)
G4 15–29 Severely decreased Nephrologist-led care; prepare for renal replacement therapy (RRT); comprehensive pre-dialysis education
G5 < 15 Kidney failure Establish RRT (haemodialysis, peritoneal dialysis, or transplant); conservative care if appropriate

KDIGO Albuminuria Categories (A1–A3)

A Category ACR (mg/mmol) Description Approximate ACR (mg/g)
A1 < 3 Normal to mildly increased < 30
A2 3–30 Moderately increased (formerly "microalbuminuria") 30–300
A3 > 30 Severely increased (formerly "macroalbuminuria") > 300

Risk Stratification Grid

Combine G and A categories. Green = low risk (monitor annually), yellow = moderate risk (monitor 6–12 monthly), orange = high risk (monitor 3–6 monthly, nephrology consideration), red = very high risk (nephrology referral, monitor 1–3 monthly).

Low Risk (Green)
G1–G2 / A1
eGFR β‰₯ 60 with no albuminuria. No other markers of kidney damage. Monitor annually; manage cardiovascular risk.
Setting: Primary care (GP-led)
Moderate Risk (Yellow)
G1–G2 / A2 or G3a / A1
Mild eGFR decline or moderate albuminuria alone. Investigate cause; optimise BP and glycaemic control; monitor 6–12 monthly.
Setting: Primary care with nephrology awareness
High / Very High Risk (Orange/Red)
G3b–G5 or A3 or GFR decline > 5 mL/min/year
Significant kidney disease. Active CKD complication management (anaemia, CKD-MBD, metabolic acidosis, hyperkalaemia). Nephrology referral. RRT planning at G4/G5.
Setting: Nephrologist-led multidisciplinary care

Dialysis Patient Assessment

Patients established on dialysis require systematic assessment at each encounter. The following domains should be evaluated:

Vascular Access (Haemodialysis)

  • Arteriovenous fistula (AVF): inspect for maturation, scars, swelling, aneurysm, infection signs. Palpate for a continuous thrill (systolic and diastolic) β€” absence suggests thrombosis. Auscultate for a bruit; a high-pitched systolic bruit may indicate stenosis.
  • Arteriovenous graft (AVG): palpate pulse and thrill; assess for signs of infection, pseudoaneurysm, or steal syndrome (cool hand, pain on exercise).
  • Central venous catheter (tunnelled): inspect exit site for erythema, discharge, tenderness; assess catheter position and function.
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NEVER take blood pressure, perform venepuncture, or place IV cannulae in the arm with a functioning AVF or AVG. Do not allow tourniquets on the access limb. Label the access limb with a "No BP / No Needle" alert bracelet.

Fluid Status

  • Assess target (dry) weight β€” weight at which the patient is normotensive and oedema-free.
  • Signs of fluid overload: peripheral oedema, raised JVP, pulmonary crackles, hypertension, weight gain between sessions.
  • Signs of dehydration: postural hypotension, dry mucous membranes, cramps during dialysis, weight loss below dry weight.

Dialysis Adequacy

  • Kt/V (single-pool): target β‰₯ 1.4 per session for thrice-weekly haemodialysis (minimum acceptable 1.2).
  • URR (urea reduction ratio): target β‰₯ 70%.
  • Assessed monthly by the dialysis unit; suboptimal adequacy may indicate recirculation, access dysfunction, or treatment time issues.

Common Dialysis Complications to Assess

Complication Assessment Points
Renal anaemia Hb target 100–115 g/L (avoid > 130 g/L); iron studies (ferritin β‰₯ 200 Β΅g/L, transferrin saturation β‰₯ 20%); ESA doses; fatigue assessment
CKD-Mineral Bone Disease Calcium, phosphate, PTH (target 2–9 Γ— upper normal), ALP, vitamin D; phosphate binder adherence; bone pain, fractures
Cardiovascular disease Blood pressure, fluid status, lipid profile, ECG, echocardiography (annually); assess for ischaemic symptoms
Dialysis-related amyloidosis Carpal tunnel syndrome, shoulder pain, bone cysts (long-term HD patients, > 5 years); Ξ²2-microglobulin levels
Infection Exit site (catheter), access site (AVF/AVG); blood cultures if febrile; hepatitis B/C screening; vaccination status
Dialysis hypotension Intradialytic BP monitoring; assess ultrafiltration rate; review dry weight; assess for autonomic neuropathy

Peritoneal Dialysis Assessment

  • Catheter exit site: inspect for erythema, tenderness, discharge, crust formation β€” scored using the Twardowski exit-site scoring system.
  • Peritonitis signs: cloudy dialysate effluent, abdominal pain, fever. Effluent cell count > 100 WBC/Β΅L with > 50% neutrophils is diagnostic.
  • PD adequacy: weekly Kt/V β‰₯ 1.7; peritoneal equilibration test (PET) for membrane function classification (high, high-average, low-average, low transporter).
  • Fluid status and ultrafiltration: assess for ultrafiltration failure; review glucose concentrations of PD solutions used.

Genitourinary Examination

The genitourinary examination should be performed in a systematic order. Always ensure patient privacy, obtain verbal consent, and offer a chaperone β€” particularly for genital examination. Explain each step before performing it.

General Inspection & Signs of Uraemia

Begin with a general inspection of the patient. In advanced CKD (stages G4–G5), look for the following stigmata of uraemia:

Sign Description Significance
Foetor uraemicus Ammonia-like (urine-like) breath odour Elevated BUN/urea; late CKD / uraemia
Sallow / yellow-brown skin Discolouration due to urochrome pigment deposition and anaemia Chronic renal failure
Scratch marks (excoriations) Pruritus secondary to uraemia, hyperphosphataemia, secondary hyperparathyroidism CKD-MBD; inadequate phosphate control
Peripheral oedema Bilateral, pitting, dependent (sacral in bedbound, ankle in ambulant) Fluid overload, nephrotic syndrome (may also have periorbital oedema, ascites)
Pallor Conjunctival, palmar, and nail bed pallor Renal anaemia (normocytic, normochromic)
Nail changes Half-and-half nails (Lindsay's nails) β€” proximal white, distal brown; onycholysis; brittle nails CKD / uraemia
Uraemic frost White crystalline deposits on skin surface (rare in modern era) Severe untreated uraemia (historically)
Pericardial rub Scratchy, biphasic rub on cardiac auscultation Uraemic pericarditis β€” medical emergency requiring urgent dialysis
Fluid overload signs Raised JVP, bibasal crackles, S3 gallop, hepatomegaly, ascites Volume overload; nephrotic syndrome or dialysis-dependent CKD
Neurological signs Asterixis (flapping tremor), confusion, peripheral neuropathy (stocking-glove), restless legs Uraemic encephalopathy, uraemic neuropathy

Blood Pressure Measurement

Blood pressure assessment is a cornerstone of genitourinary examination. Hypertension is both a cause and consequence of CKD.

  • Standard technique: Patient seated, rested β‰₯ 5 minutes, arm supported at heart level, appropriate cuff size (bladder encircling β‰₯ 80% of arm circumference). Take at least two readings 1–2 minutes apart; use the mean.
  • Ambulatory blood pressure monitoring (ABPM) or home BP monitoring (HBPM) is recommended to exclude white-coat hypertension and detect masked hypertension (normal clinic BP but elevated out-of-office BP β€” common in CKD).
  • Postural (orthostatic) BP: measure lying (after 5 minutes supine) then standing at 1 and 3 minutes. A drop of β‰₯ 20 mmHg systolic or β‰₯ 10 mmHg diastolic is significant orthostatic hypotension β€” common in autonomic neuropathy (diabetes, uraemia), volume depletion, and antihypertensive overtreatment.
  • Inter-arm difference: measure both arms at initial assessment. A difference of > 20 mmHg systolic suggests subclavian stenosis, aortic coarctation, or aortic dissection.
  • CKD targets: BP < 130/80 mmHg for most CKD patients with albuminuria (A2–A3); < 140/90 mmHg for CKD without albuminuria. In dialysis patients, assess pre- and post-dialysis BP and interdialytic BP trends.
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In suspected renal artery stenosis, an abdominal bruit may be auscultated in the epigastrium or flanks. This is a systolic-diastolic (continuous) bruit best heard with the bell of the stethoscope during held expiration.

Abdominal and Renal Examination

Inspection

  • Inspect for surgical scars (nephrectomy, transplant β€” typically a curvilinear incision in the iliac fossa for renal transplant), peritoneal dialysis catheter exit site, suprapubic catheter.
  • Abdominal distension (ascites in nephrotic syndrome, hepatomegaly in polycystic kidney disease, bladder distension).

Palpation of the Kidneys

The kidneys are normally not palpable in adults. A palpable kidney may indicate hydronephrosis, polycystic kidney disease (PKD), renal cell carcinoma, or compensatory hypertrophy (solitary kidney).

  • Bimanual (ballottement) technique: Place one hand posteriorly in the renal angle (flank) and the other anteriorly on the abdomen just below the costal margin. During deep inspiration, press the posterior hand firmly forward. The kidney, if palpable, will be ballotable (felt to "bounce" between the two hands). A non-tender, large, ballotable, smooth mass suggests hydronephrosis or PKD. A firm, irregular, non-tender mass may be renal cell carcinoma.
  • Transplant kidney: located in the iliac fossa (usually the right); palpate gently β€” it is superficial. Assess for tenderness (rejection, infection) and size (swelling may indicate rejection).
  • Renal angle tenderness: percussion (fist percussion) over the costovertebral angle. Tenderness suggests pyelonephritis, perinephric abscess, renal calculus causing obstruction, or renal capsular distension.

Bladder Palpation

  • A distended bladder is palpable as a suprapubic mass arising out of the pelvis, dull to percussion, and not ballotable. Percuss from the umbilicus downwards β€” the transition from resonance to dullness marks the upper border of the distended bladder.
  • Acute urinary retention requires urgent catheterisation. Record the post-void residual volume (PVR) β€” PVR > 100 mL is abnormal; > 300 mL suggests significant retention.

Digital Rectal Examination (DRE)

DRE is an essential component of the male GU examination, particularly for prostate assessment:

  • Patient in the left lateral (Sims') position with knees drawn up.
  • Inspect the perianal region first (haemorrhoids, fissures, fistulae, warts, skin tags).
  • Lubricate the gloved index finger and insert gently. Assess anal sphincter tone.
  • Prostate palpation: The prostate lies anterior. A normal prostate is approximately walnut-sized, with a palpable central sulcus, and feels rubbery. BPH: enlarged, smooth, rubbery with loss of the central sulcus. Prostatitis: tender, boggy. Prostate carcinoma: hard, irregular, nodular, loss of median sulcus, fixed to surrounding structures.
  • Note any rectal masses, impacted faeces, or blood on the glove.

Urinalysis & Male Genitalia Examination

Urinalysis

Urinalysis is one of the most informative bedside investigations in genitourinary medicine. It includes dipstick analysis, visual assessment (colour, clarity), and microscopy.

Specimen Collection

  • Midstream urine (MSU): clean-catch specimen; instruct the patient to clean the glans/periurethral area, begin voiding, then collect the midstream portion in a sterile container. This is the standard for UTI diagnosis.
  • First-void urine: first 10–20 mL of the stream β€” preferred for STI testing (chlamydia, gonorrhoea NAAT).
  • Catheter specimen: aspirated from the sampling port of an in-situ catheter (never from the drainage bag).

Visual Assessment

Appearance Significance
Clear, pale yellow Normal, well-hydrated
Dark yellow / amber Concentrated (dehydration), bilirubinuria
Red / pink Haematuria, myoglobinuria, porphyria, beetroot, rifampicin
Brown / cola-coloured Glomerular haematuria (dysmorphic RBCs), myoglobinuria (rhabdomyolysis), severe dehydration
Cloudy / turbid UTI (pyuria), phosphaturia, chyluria
Milky white Chyluria (lymphatic obstruction), severe phosphaturia
Green Pseudomonas UTI, propofol, methylene blue, amitriptyline

Dipstick Parameters

Parameter What It Detects Clinical Significance False Positives / Negatives
pH Urine acidity/alkalinity (range 5.0–8.5) Alkaline: UTI (urease-producing organisms: Proteus), renal tubular acidosis (Type 1). Acidic: metabolic acidosis, uric acid stones FP: prolonged standing, old specimens. FN: rare
Specific gravity (SG) Urine concentration (1.001–1.035) Low (< 1.005): dilute (DI, overhydration, CKD). High (> 1.025): concentrated (dehydration, SIADH) FP: protein, glucose. FN: alkaline urine
Protein Primarily albumin; detects β‰₯ 300 mg/L (1+) Nephrotic syndrome, glomerulonephritis, UTI, pre-eclampsia, orthostatic proteinuria, exercise. Positive dipstick protein should be confirmed with ACR (urine albumin:creatinine ratio) FP: alkaline urine, concentrated urine, quaternary ammonium antiseptics. FN: Bence Jones protein (myeloma), dilute urine
Blood (haemoglobin / myoglobin) Free haemoglobin, myoglobin, or intact RBCs (β‰₯ 5 RBCs/Β΅L equivalent) Haematuria (glomerulonephritis, stones, UTI, malignancy), myoglobinuria (rhabdomyolysis), menstruation (contamination) FP: myoglobin (positive even without RBCs on microscopy), menstrual contamination, vigorous exercise, oxidising agents (bleach). FN: ascorbic acid (vitamin C) β€” reduces sensitivity
Glucose Glycosuria (threshold ~10 mmol/L blood glucose in normoglycaemic renal threshold) Diabetes mellitus (uncontrolled), gestational diabetes, renal glycosuria (low renal threshold), SGLT2 inhibitor use FP: SGLT2 inhibitors (empagliflozin, dapagliflozin). FN: ascorbic acid
Ketones Acetoacetic acid (and partial acetone); does not detect Ξ²-hydroxybutyrate Diabetic ketoacidosis (DKA), starvation, ketogenic diet, alcohol ketoacidosis, vomiting FP: some medications (levodopa, captopril). FN: Ξ²-hydroxybutyrate not detected (predominant ketone in DKA β€” use serum ketones if suspected)
Nitrites Bacterial conversion of urinary nitrate to nitrite (Gram-negative organisms: E. coli, Klebsiella, Proteus, Enterobacter) Positive nitrites + leucocyte esterase = high predictive value for UTI. Specificity ~90% FP: rare. FN: Gram-positive organisms (Enterococcus, Staphylococcus saprophyticus) do not convert nitrate β†’ nitrite; urine in bladder < 4 hours (insufficient conversion time); dietary nitrate deficiency; dilute urine
Leucocyte esterase (LE) Enzyme released by neutrophils / WBCs in urine Pyuria β€” suggests UTI, interstitial nephritis, kidney stones, STI, bladder tumour FP: vaginal contamination, trichomoniasis, strong oxidising agents. FN: ascorbic acid, high glucose, high protein, tetracycline, cephalexin

Urine Microscopy (Key Findings)

Finding Significance
RBCs (> 10/Β΅L) Microscopic haematuria; dysmorphic RBCs and RBC casts suggest glomerular origin (glomerulonephritis)
WBCs (> 10/Β΅L) Pyuria; UTI, interstitial nephritis, STI
RBC casts Glomerulonephritis (IgA nephropathy, lupus nephritis, vasculitis) β€” pathognomonic
WBC casts Pyelonephritis, interstitial nephritis
Granular / waxy casts CKD, ATN (acute tubular necrosis)
Broad casts CKD (formed in dilated, hypertrophied tubules of remaining nephrons)
Casts with oval fat bodies / fat droplets Nephrotic syndrome (lipiduria)
Crystals (calcium oxalate) Oxalate stones, ethylene glycol poisoning
Crystals (uric acid, coffin-lid shaped) Uric acid stones, gout
Crystals (struvite / triple phosphate β€” coffin-lid) Proteus UTI (staghorn calculi)
Bacteria UTI (confirm with culture); may be contamination if mixed flora
Yeast (Candida) Candiduria β€” common in catheterised patients, diabetes, immunosuppression
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Positive dipstick blood with no RBCs on microscopy: Think myoglobinuria (rhabdomyolysis). Check serum CK and potassium urgently. Positive dipstick protein with negative ACR: consider Bence Jones proteinuria (multiple myeloma) β€” request serum free light chains and urine protein electrophoresis.

Male Genitalia Examination

The male genitalia examination is an essential component of the genitourinary assessment. Always offer a chaperone and ensure adequate privacy.

Penis

  • Inspection: retract the foreskin (if uncircumcised) to inspect the glans and coronal sulcus. Note circumcision status. Look for:
    • Meatal position β€” hypospadias (ventral) or epispadias (dorsal)
    • Urethral discharge β€” clear/mucoid (chlamydia), purulent (gonorrhoea), blood-stained (urethral trauma, carcinoma)
    • Ulcers β€” chancre (primary syphilis, painless), herpes simplex (multiple shallow painful vesicles/ulcers), chancroid (painful, undermined edges)
    • Warts β€” condylomata acuminata (HPV); condylomata lata (secondary syphilis β€” flat, moist, grey-white)
    • Balanitis / balanoposthitis β€” candidal infection (common in diabetes), Zoon's balanitis (lichenoid)
    • Peyronie's disease β€” palpable fibrous plaque on the tunica albuginea; penile curvature on erection
    • Penile carcinoma β€” erythroplasia of Queyrat, Bowen's disease, or frank squamous cell carcinoma

Scrotum and Contents

  • Inspect the scrotal skin for rashes (tinea cruris, scabies, eczema), swelling, sinuses, and erythema.
  • Palpate each testis separately between thumb and fingers. Normal testis: ovoid, firm, smooth, ~4–5 cm long axis in adults. Assess for:
    • Testicular mass: any firm, irregular, non-tender intratesticular mass is a germ cell tumour until proven otherwise. Refer urgently for scrotal ultrasound and serum tumour markers (AFP, Ξ²-hCG, LDH).
    • Epididymis: lies posterolateral to the testis. Tender, swollen epididymis = epididymitis (STI if < 35 years; UTI if > 35 years). May have reactive hydrocele.
    • Hydrocele: fluid-filled tunica vaginalis; transilluminates (use a torch in a darkened room β€” a hydrocele will glow red). Non-tender. Distinguish from hernia (does not transilluminate, reducible).
    • Varicocele: dilated pampiniform venous plexus; feels like a "bag of worms"; more common on the left; accentuated by standing and Valsalva manoeuvre. Classically associated with infertility.
    • Spermatocele: epididymal cyst; separate from the testis; transilluminates.
    • Testicular torsion: acute severe pain, high-riding testis with transverse lie, absent cremasteric reflex, nausea/vomiting. Surgical emergency β€” detorsion within 6 hours for testicular salvage. Do not delay for imaging if clinical suspicion is high.

Inguinal Canal

  • Indirect inguinal hernia: palpated at the external inguinal ring; invaginate the scrotal skin with the examining finger into the external ring. Ask the patient to cough β€” an impulse suggests hernia.
  • Direct inguinal hernia: medial to the inferior epigastric vessels; reducible, less likely to strangulate than indirect hernias.
  • Femoral hernia: below and lateral to the pubic tubercle; more common in women; higher risk of strangulation.

Lymph Node Assessment

  • Palpate inguinal lymph nodes (superficial and deep) β€” enlargement may indicate STI, genital malignancy, or lower limb infection.
  • Left supraclavicular lymphadenopathy (Virchow's node) in association with a testicular mass may indicate metastatic testicular cancer.

Special Populations

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Pregnancy

eGFR interpretation: GFR physiologically increases by 40–60% in normal pregnancy due to increased renal blood flow and glomerular hyperfiltration. A creatinine of 80 Β΅mol/L in pregnancy may represent significant renal impairment.
Proteinuria: UP:UC ratio β‰₯ 30 mg/mmol in pregnancy should prompt evaluation for pre-eclampsia (with hypertension, features of end-organ damage). ACR alone is less reliable in pregnancy β€” 24-hour urine collection may be needed.
Blood pressure: Gestational hypertension: β‰₯ 140/90 mmHg after 20 weeks. Pre-eclampsia: hypertension + proteinuria or other end-organ involvement. Severe: β‰₯ 160/110 mmHg β€” emergency treatment required (IV labetalol, oral nifedipine, or IV hydralazine).
UTI in pregnancy: Asymptomatic bacteriuria must be treated (risk of pyelonephritis and preterm labour). Safe antibiotics: cephalexin, nitrofurantoin (avoid at term β€” risk of neonatal haemolysis), amoxicillin. Avoid trimethoprim (folate antagonist in first trimester), fluoroquinolones, aminoglycosides.
Dialysis patients: Rare but possible; requires intensified dialysis (β‰₯ 36 h/week) and close obstetric monitoring. Pregnancy is high-risk in women with G4–G5 CKD.
Male genitalia examination: Not applicable in pregnancy assessment but relevant for male partners in fertility evaluation.
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Paediatrics

CKD-EPI equation is not validated in children < 18 years. Use the bedside CKiD (Chronic Kidney Disease in Children) formula or the updated U25 equation for young people.
Normal eGFR by age: Neonates 15–30 mL/min/1.73 mΒ²; rises to adult levels by 2 years (~90–120 mL/min/1.73 mΒ²).
Urine collection: Clean-catch MSU is feasible from toilet-trained children. For infants, use adhesive urine collection bags (suprapubic aspiration or catheterisation if sterile specimen required urgently).
Nocturia in children: Primary nocturnal enuresis (bedwetting) is common up to age 5–7; investigate if daytime symptoms or new-onset secondary enuresis (UTI, constipation, diabetes, psychological stress).
Testicular examination (paediatric): Undescended testis (cryptorchidism) β€” palpate along the inguinal canal; retractile vs truly undescended. Neonatal testicular torsion (painless, hard scrotal mass β€” do not confuse with hydrocele). Testicular torsion peaks at 12–18 years (acute onset).
Phimosis vs paraphimosis: Physiological phimosis is normal in boys < 5 years (non-retractable foreskin). Paraphimosis is an emergency β€” the retracted foreskin cannot be reduced, causing venous congestion and oedema of the glans; requires urgent manual reduction Β± dorsal slit.
πŸ‘΄

Elderly

eGFR decline: eGFR declines with age (~1 mL/min/1.73 mΒ² per year after age 40); an eGFR of 55 in an 85-year-old may be "normal for age" but still warrants monitoring.
Nocturia: Very common in the elderly β€” multifactorial (age-related bladder changes, BPH, CKD, heart failure, medications, sleep disorders). Avoid attributing solely to BPH without thorough assessment.
Incontinence: Prevalence increases with age; often multifactorial. Distinguish stress, urge, overflow, and functional types. Avoid indwelling catheters unless absolutely necessary (infection risk, immobility).
DRE in elderly males: Still important for prostate assessment, but a normal DRE does not exclude prostate cancer. Consider PSA alongside DRE for prostate cancer screening in men with > 10-year life expectancy (discuss in the context of the NHMRC PSA testing guidelines).
Orthostatic hypotension: Very common in elderly CKD patients on antihypertensives; check lying-standing BP routinely; aim for systolic BP 120–130 mmHg but avoid excessive drops.
Drug dosing: Always adjust renally cleared medications (DOACs, digoxin, gabapentin, lithium, allopurinol, metformin) to eGFR. Metformin is contraindicated when eGFR < 15; dose reduction at eGFR 30–45.
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Renal Impairment

When eGFR is unreliable (extremes of body composition, amputees, paraplegia, muscle wasting), use cystatin C-based eGFR or measured GFR (iohexol clearance β€” available at major Australian renal units).
Medication safety: Use the Australian Medicines Handbook (AMH) renal dosing guide and the renal drug reference (e.g., renaldrg.com.au) for all prescriptions. Common agents requiring dose adjustment: enoxaparin, DOACs, gabapentin, pregabalin, lithium, colchicine, allopurinol, methotrexate.
Contrast-induced AKI: Risk assessment before IV iodinated contrast (eGFR < 45 = moderate risk; < 30 = high risk). Pre-hydration with 0.9% NaCl (1 mL/kg/h for 6–12 h pre- and post-procedure). Avoid nephrotoxic drugs for 48 h peri-procedure. Use low/iso-osmolar contrast. Check creatinine 48–72 h post-contrast.
Renal transplant patients: Immunosuppressed; assess graft function (eGFR, proteinuria); immunosuppression drug levels (tacrolimus, cyclosporine, sirolimus); infection screen; malignancy surveillance (skin cancer, PTLD).
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Hepatic Impairment

Hepatorenal syndrome (HRS): AKI in the setting of advanced liver disease (cirrhosis + ascites). Type 1: rapidly progressive (doubling of creatinine to > 226 Β΅mol/L in < 2 weeks). Type 2: slowly progressive. Diagnosis requires exclusion of other causes. Managed with terlipressin (Authority Required PBS) + albumin; liver transplant is definitive.
eGFR limitations: CKD-EPI equation may overestimate GFR in cirrhosis due to muscle wasting and low creatinine production. Measured GFR (iohexol or iothalamate) preferred for pre-transplant assessment.
Drug metabolism: Many drugs are both hepatically and renally cleared (e.g., morphine, oxycodone); dual impairment increases toxicity risk dramatically. Avoid NSAIDs in cirrhosis (portal hypertension, renal vasoconstriction, GI bleeding).
πŸ›‘οΈ

Immunocompromised

UTI in immunocompromised: Higher risk of atypical and resistant organisms (Pseudomonas, ESBL-producing E. coli, fungal UTI). Lower threshold for urine culture (not just dipstick) and imaging. Emphysematous pyelonephritis (gas-forming UTI) is a urological emergency β€” more common in diabetics.
HIV and GU examination: Increased risk of STIs (syphilis, herpes, HPV-related anal and penile cancer), HIV-associated nephropathy (HIVAN β€” collapsing FSGS, presents with heavy proteinuria and rapid eGFR decline), and CKD from tenofovir (proximal tubular toxicity β€” Fanconi syndrome).
Transplant recipients: BK polyomavirus nephropathy (decoy cells on urine cytology, BK viral load monitoring). CMV cystitis. Post-transplant lymphoproliferative disorder (PTLD). Calcineurin inhibitor nephrotoxicity (tacrolimus, cyclosporine).
Chemotherapy: Tumour lysis syndrome (hyperuricaemia, hyperkalaemia, hyperphosphataemia, AKI) β€” prophylaxis with rasburicase or allopurinol. Cisplatin nephrotoxicity (dose-related, requires aggressive hydration and magnesium replacement).

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Kidney disease is one of the most significant chronic conditions disproportionately affecting Aboriginal and Torres Strait Islander Australians. The AIHW reports that Indigenous Australians develop CKD at 3.8 times the rate of non-Indigenous Australians, with onset at a younger age and faster progression to kidney failure. In some remote and very remote communities, the incidence of treated kidney failure is 6–20 times the national average. Culturally safe, trauma-informed care is essential in all genitourinary assessments.

CKD prevalence & incidence
Indigenous Australians have 3.8Γ— the rate of CKD and up to 6–20Γ— the rate of treated kidney failure in remote communities compared with non-Indigenous Australians. Type 2 diabetes and rheumatic heart disease (with subsequent renal involvement) are major contributors. Albuminuria screening should be integrated into annual Indigenous health checks (MBS Item 715).
Remote access challenges
Patients in remote and very remote communities often cannot access nephrology services, dialysis units, or specialist GU examination without significant travel and cultural disruption. Many patients are evacuated from communities for dialysis β€” separated from family, Country, and community β€” contributing to psychological distress and poor adherence. Point-of-care testing (POCT) for eGFR, ACR, and urinalysis is available in many Aboriginal Community Controlled Health Organisations (ACCHOs) via the Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) programme.
Cultural safety in GU examination
Male genitalia examination and DRE may be culturally sensitive. Same-gender clinicians and chaperones should be offered. Avoid assuming understanding β€” use interpreters where English is not the first language (many Indigenous Australians speak English as a second, third, or fourth language). Explain the purpose and process of each examination step clearly and obtain explicit consent. "Sorry business" and cultural obligations may affect attendance and should be accommodated.
Screening & early intervention
Annual kidney health checks under MBS Item 715 should include: eGFR, ACR, blood pressure, HbA1c (if diabetic), and urinalysis. RACGP and Kidney Health Australia recommend screening Indigenous Australians from age 18 (vs age 45 for non-Indigenous). Early nephrology referral (G3a + A2 or A3) is crucial for timely intervention. Streptococcus-related glomerulonephritis (post-streptococcal GN, rheumatic fever-related renal disease) remains more prevalent in remote Indigenous communities.
Dialysis access & outcomes
Indigenous Australians are more likely to commence dialysis as an emergency (catheter start) rather than with planned access (AVF or PD). This is associated with higher infection rates, hospitalisation, and mortality. Pre-emptive AVF creation and PD-first strategies in remote areas should be considered. Satellite dialysis units in regional centres and community-based dialysis (e.g., Purple House / Western Desert Nganampa Walytja Palyantjaku Tjutaku Aboriginal Corporation) have improved access for remote communities.
Social determinants & comorbidities
CKD in Indigenous Australians coexists with high rates of type 2 diabetes (β‰ˆ 3Γ— non-Indigenous rates), cardiovascular disease, rheumatic heart disease, obesity, smoking, and socioeconomic disadvantage. A holistic, multidisciplinary approach β€” integrating renal care with diabetes management, cardiac monitoring, smoking cessation, nutrition (addressing food insecurity in remote communities), and mental health support β€” is essential. Link workers and Aboriginal health practitioners should be involved in care planning.
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MBS Item 715: Aboriginal and Torres Strait Islander peoples are eligible for a comprehensive annual health assessment (MBS Item 715), which should include kidney health checks (eGFR, ACR, BP). Ensure this is offered and documented at every annual review. Kidney Health Australia's "Kidney Health for All" resources provide culturally appropriate patient education materials in multiple Indigenous languages.

πŸ“š References

  1. 1. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl. 2013;3(1):1–150.
  2. 2. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021;99(3S):S1–S87.
  3. 3. Australian Institute of Health and Welfare (AIHW). Chronic Kidney Disease in Aboriginal and Torres Strait Islander People 2023. Cat. no. PHE 320. Canberra: AIHW; 2023.
  4. 4. Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). 45th Annual Report 2022. Adelaide: ANZDATA; 2023.
  5. 5. Kidney Health Australia. Chronic Kidney Disease Management in Primary Care. 4th ed. Melbourne: Kidney Health Australia; 2020.
  6. 6. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice. 9th ed. East Melbourne: RACGP; 2016 (updated 2023).
  7. 7. Talbot B, Abeyaratne A, Sherrington S, et al. Measured GFR in the Australian population: a systematic review. Nephrology. 2021;26(12):959–968.
  8. 8. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
  9. 9. National Health and Medical Research Council (NHMRC). PSA Testing for Prostate Cancer in Asymptomatic Men: Information for Health Professionals. Canberra: NHMRC; 2014 (updated 2022).
  10. 10. Hughes JT, Maple-Brown LJ, Thomas M, et al. Chronic kidney disease in Aboriginal and Torres Strait Islander people: the eGFR Study. Med J Aust. 2022;216(8):393–399.
  11. 11. National Aboriginal Community Controlled Health Organisation (NACCHO). National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People. 3rd ed. West Melbourne: RACGP/NACCHO; 2018.
  12. 12. Agar JW, Perkins A, Tjipto A. Solar-assisted haemodialysis in remote Australia: the Purple House experience. Nephrology. 2021;26(1):5–12.
  13. 13. Schwartz GJ, MuΓ±oz A, Schneider MF, et al. New equations to estimate GFR in children with CKD. J Am Soc Nephrol. 2009;20(3):629–637.
  14. 14. Australian Institute of Health and Welfare (AIHW). Kidney and Urinary Tract Disease in Australia. Cat. no. PHE 225. Canberra: AIHW; 2023.
  15. 15. Tattersall J, Dekker F, HeimbΓΌrger O, et al. When to initiate dialysis: updated guidance following publication of the Initiating Dialysis Early and Late (IDEAL) study. Nephrol Dial Transplant. 2011;26(7):2082–2086.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

πŸ“š References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, LandewΓ© RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing β€” misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFΞ± blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

πŸ“š References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, LandewΓ© RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing β€” misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFΞ± blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).